Take Up Thy Stethoscope And Walk

Wednesday, 3 August 2016

I realise it's been almost a year since I last posted, so I think some updates are necessary: I passed my medical school finals in June 2016 (on the first attempt thankfully!). I graduated medical school in July. I am now on the LRMP. I completed my pre-work shadowing this week. I am starting as a Foundation Year 1 doctor tomorrow, something I never thought I'd be able to become 9 years ago when I received a less-than-stellar chemistry AS level grade which put medical school (temporarily) out of my reach. Something which seemed to be an impossible dream during the first two years of my degree when I was struggling to break out of a 2:2 average and mentally blocked; unable to move on from the blow to my self-confidence which had occurred following the first big disappointment of my academic life, after many years of getting top marks with minimal effort (those bloody AS levels).

Oh Warwick. I never went to your open day - I applied merely on the basis that my UKCAT was high enough to almost guarantee an interview. I'd never set foot in the West Midlands until my interview day 4.5 years ago. I certainly remember my gut feeling on my interview day being that I really liked it here and would be very happy indeed with an offer (and my blog post from that day attests to that). I never found out who my interviewer was, just a guy who was happy to let me go off topic and confess that the Kinks were great music to unwind to and made me happy. I hoped he was a member of the regular staff who I'd meet in a lecture or on placement, and we might laugh about it, but apparently not.

But in all honesty, Warwick wasn't my first choice deep down. London, my hometown, was where I wanted to stay. But without a GEP offer, London's 5 year offer was financially out of reach, and I didn't want to spend an extra year being a student anyway. So I came here, very happy and extremely grateful, and not at all regretful, but still cautious and slightly nervous about leaving a city where I'd lived for most of my life.

Those first few weeks in September 2012 are now so hazy - community placements, clinical skills practice with classmates in our group study rooms: "first inspect from the end of the bed" (actually two desks laid together). Random memories: how different campus looked in 2012 compared to today, the songs at my first Medics' Revue, the diagnosis of the patient we were taken to see on our first half-day on the wards at the start of our second term in January 2013 etc. It was all very different to London, but I still really liked it here - there were lots of new places to see and explore, so I was confident I'd made the right choice in coming here.

Starting clinical placements in February 2014 unfortunately clashed with a perfect storm of personal problems: relationship difficulties, financial stresses, and health worries, culminating in a sense of chronic frustration with my perceived failures as a young adult. Unfortunately my medical school was caught in the crossfire of this. These problems would have likely happened at any other place, as they are just part of life and getting older - but for well over a year I struggled with these issues (often by myself without telling anyone), and the rigmarole and bureaucracy associated with placement made it quite easy to misdirect the stress from my personal life to simply hating my medical school and thinking "this just wouldn't have happened if I hadn't come here".

It was only until I went away on elective in March 2015, to another part of the UK and saw first hand that medical schools and medical students are basically the same everywhere, that I understood that Warwick wasn't the issue.

When I was preparing for finals I did thousands of online MCQs, and I realised very early on that the answer I went for the first time was almost always correct compared with if I went back, re-assessed the question, and changed my reply. When it comes to MCQs, I am not someone who should second guess myself - I need to trust my gut instinct.

And so it goes with Warwick, who I now know I was right about in Feb 2012. When I visited for my interview day and felt comfortable and could see myself here, that was gut instinct. And when I got back from elective, feeling in a much better place, I was able to reconnect with that initial feeling I had about the place.

Because of this, the latter half of my third year and my entire final year have been some of the happiest times of my life. I began to feel much calmer and relaxed as a person, my friendships developed and deepened (probably why I felt the need to vent here less), and most importantly, once I felt comfortable and happy with the place I was in, I quite suddenly felt a lot more confident as a medical student. Certainly I still had wobbles and days when I'd come home from placement and feel like an absolute imposter, but these days became more and more infrequent, such that in the run up to Finals, I remember feeling calmer and more ready than before any other exams I'd taken in my life - even though this was the most important one. I finished with the highest results I'd gained at any point in my eight year university career, a result I am genuinely really proud of and happy with. So in short, I am very glad that my med school application brought me here, and if I could go back 4.5 years and change things, I wouldn't.

My one wish for this coming year, which I write 7 hours before I get up for my first day as an FY1 is that I don't become jaded or cynical about this job and the people I meet and care for. I don't care if I feel stupid or thick or if I'm not good at doing cannulae. Those things can change and will improve with time. But the hospital can be such a stressful place, and life itself is stressful anyway - I just don't want my job which I've worked so hard for, to become caught in the crossfire, like medical school was for a year or so. The difference is that having already gone through that period of maturation and self-awareness in medical school, I will recognise the warning signs and not let it happen to me as a doctor.

I remain optimistic that this job, and the art and science that I have been fortunate enough to be trained in will continue to be a hugely significant and positive part of my identity and personality. I think back to my ten year old self, deciding in a simultaneously precocious and naive way that this job would be something fun and fulfilling to do as a grown up, and I think that I have done right by him. That makes me feel like I've arrived where I want to be, so I'm going to try my very best to enjoy it for as long as I am able to.

Friday, 4 September 2015

I'm back at uni and officially a final year now! Before that, I had a two week summer break where I went home and chilled out - O&G had been a really intense block with night shifts and a pretty tough end of placement exam. Most end of placement exams are seen as a bit of a formality, but this one really was quite difficult indeed, though thankfully I managed to pass. So yeah, the two week break was pretty welcome but I'm glad to be back now and getting into the swing of things again!

I'm now on a general medicine block which involves placements in two departments: neurology and geriatrics. I'm pleased to have received this combination since neurology is quite a difficult area of medicine, so it will be good to receive eight weeks of experience and teaching in it. And similarly, geriatrics is such a vast specialty with patients with lots of different presenting complaints, co-morbidities etc, it will be a good opportunity to brush up on all the internal medicine I've forgotten!

Mind you, before this placement started, we had a two day session on "complementary and alternative medicines" (CAM). I think this is a GMC requirement, not a med school one, so it's just something everyone has to do.

I went along and I tried my best to keep an open mind. I really did. But it's all just so wishy-washy and plain nonsensical. Setting aside the lack of evidence base for most of the "treatments", the theories behind how they (supposedly) work were so frustrating to hear. The number of fingers you take the radial pulse with can indicate where a pathology might be, the colour of one's tongue can reveal information about a person's inner state, transmission of different forms of energy etc etc. When one of the speakers started talking about "mind-body-spirit", well, that's when I fully switched off. Spirit, for crying out loud. Is this medical school or a seminary?

Honestly, if medical school was Hogwarts, this particular class would have been Divination.

The end result of those two days was that it merely re-affirmed what I believed before, that CAM is mostly used by patients who have conditions which aren't that well treated or understood by evidence based medicine - probably because the conditions themselves are quite...controversial...in terms of their aetiology and pathophysiology e.g. fibromyalgia, ME, IBS, etc. Certainly CAM does seem to help some people, and whilst I'm no fan of the big pharmaceutical companies, I can't help but wonder how much of CAM actually works and how much is a placebo effect and a tidy money spinner for its "practitioners".

Wednesday, 5 August 2015

I am slowly turning into a (potential) doctor. It's finally beginning to hit me. The excuses are beginning to run out. The final years year above me graduated nearly a month ago. Their names are on the GMC's Register. Seriously, I can look up people I've got hammered with and seen cross-dressing as naughty nurses and they are listed as actual mofo-ing doctors now. They are not final years, I am now a final year. A student in the most senior class in the medical school. And today, the first Wednesday of August, the year above me began work in hospitals up and down the country (a day affectionately known in the business as "Black Wednesday"). Which means that next year, exams permitting, it will be my turn. I am one year away from my very own Black Wednesday. Today is my Grey Wednesday, if you will.

It's quite a realisation. People will actually expect me to know shit and do shit. Not everything by any means, but still, some things.

And I feel ever-so-very-slightly incompetent pretty much all the time.

There's a year left til Black Wednesday. 9 months til Finals. 3 more placements til Revision Block. 4 months til the SJT. 2 months til I submit my job application. All these numbers and deadlines, counting down the months til the day of judgement and reckoning which will finally answer that question I've been asking myself for so many years now..."so, Grumpy, did you actually think you'd be good enough to be a doctor?".

With all this giddy stress/occasional feeling of impending doom going around my head, it's no wonder lately I've been feeling torn by a near daily desire to want to enjoy my remaining time as a layabout student by going out and getting hammered as much and as often as possible or staying indoors and attempting to memorise every word of my textbooks for fear of voiding the past seven years of higher education. For the record, my social life is moribund and I haven't been properly out in forever, so at the moment I'm definitely more in the latter camp than the former.

As far as obstetrics and gynaecology goes, with one more week to go, I can safely say that it's been a really decent block. The clichés about childbirth are all completely true. It is life-affirming. It is intense. It's not like TV. Watching a woman go through labour honestly made me forget to breathe at times (usually when she was pushing) because I felt so tense myself. But in a good way. I really do love the "human drama" side of medicine. It's why I'm still here. And an uncomplicated birth is surely the best antidote there is to every crappy thing I've seen in the hospital throughout the years. It is the perfect opposite of death and illness. So yes, it's been enjoyable. Has it made me want to be an obstetrician or gynaecologist? No, but still, I've had a good few weeks and it's been a great end to my third year of medical school!

Monday, 6 July 2015

Perhaps it's because they're seeing ladies who are quite often very anxious about a lump, but the breast surgery team struck me as a compassionate and friendly bunch. The consultant we were under for two weeks was a really good guy and was keen to get us involved in examining the patients. This was very useful since up til then the only time I had ever performed breast examinations had been on a mannequin during first year OSCEs! This placement hasn't convinced me to become a breast surgeon but it was an enjoyable two weeks and I had a good time and felt like I learnt a great deal.

ENT surgery

Back when I was in sixth form I completed three hospital work experience placements - one in immunology, one in coronary care, and one in audiology. During the audiology placement I was fortunate enough to be able to spend a day with the ear, nose, and throat team. I would say that that single day was the most useful work experience I did and it was from that which I based the bulk of my personal statement.

Fast forward seven or eight years and I got to go back to ENT for another fortnight. Ears are quite a specialist area which you don't really see much of elsewhere in medicine (unless you're a GP or an audiovestibular physician) so I was glad we were able to get some experience in it. The ENT consultant we were under was quite possibly the most simultaneously chilled out and enthusiastic doctor I have ever worked under - definitely a great advertisement for his specialty and a very enjoyable two weeks. I don't really wish to be a surgeon, but if I did I think ENT would be one area I'd be happy to work in - good mixture of medical and surgical cases, no rectal exams (seriously), wide age range of patients, most patients see an improvement in their quality of life...what's not to like?

Shame you have to put up with other surgeons and trainee surgeons before you get there though, which brings me onto...

Colorectal surgery

For the final two weeks of our placement we went back to the firm we originally started with. The consultant here was nice enough, if rather taciturn, and his registrar was rather more talkative...but not in a particularly helpful way (as described in my previous post).

I'm not sure what it is about surgical training that seems to encourage this sort of attitude - the bluntness, the lack of engagement with ones juniors except when it comes to grilling them, the gleeful pouncing on any misstep in the recital of some obscure piece of anatomy, etc, etc. Perhaps it's because surgery involves comparatively more rote memorisation (procedures, anatomy, etc) than other specialties, that it ends up breeding neuroticism and competitveness about who can basically be the best parrot when it comes to memorising anatomy. Or maybe it's something else entirely and I'm just being too precious.

Either way, that was my last surgical placement of medical school (O&G does involve surgery, but it also involves a lot of medical management so it's not pure surgery). I have enjoyed the experience and found the range of patient conditions and presentations interesting to clerk in and read about, but ultimately I don't think it's really for me!

Tuesday, 5 May 2015

During my time as a medical student I have come to realise that the stereotypes about surgeons which abound in books, films and TV aren't really true. Not that I ever believed you were all a bunch of "ignorant scalpeljocks" to begin with (to quote the good Dr Cox), but I had always wondered if it was true that some of you are renowned for being very socially inept.

So, on this note, when you tell me off in front of the HCAs for "slouching" in your afternoon clinic, please bear in mind the following:

1) That I am only slouching because I was sat on the edge of the examination couch because there was no chair available.

2) That last week when I stood instead of sitting, you told me that I shouldn't "loom". But this was most likely your attempt at a tongue-in-cheek comment, so fine, that didn't bother me.

3) That I was probably slouching because my back hurts after being up and about since your 8 AM ward round where you largely ignored me.

4) That whilst slouching probably doesn't look great, neither does you rolling your eyes at a question one of my medical student colleagues asked when he was clerking in a patient. He didn't notice your annoyance because he was too busy taking his history, but I did. And perhaps, so did the patient. Hopefully the patient didn't think you were rolling your eyes at THEM, because something tells me that that probably comes off as a tad more unprofessional than slouching.

I don't really know what possesses you to act in this way - it doesn't make you seem particularly impressive or scary, merely a bit socially awkward. But then again, that seems to be par for the course for some in your chosen specialty.

But I must thank you for showing me exactly how NOT to behave towards my future students, should I ever become a registrar.

Thursday, 30 April 2015

Block: Colorectal surgery, week 1
Okay so I've been back at med school for a week now, currently on an eight week surgical attachment which will see me rotate through colorectal, breast, and ear, nose and throat surgery. I don't mind surgical blocks - the clinics are normally good, but standing at the back of theatre for hours staring at the backs of the consultant and registrar is not that educational. If only there was more opportunity to be scrubbed in, even being the retractor monkey is more fun than simply standing around!

Also, surgeons are infamous for being massive grillers - they will ask you awkward questions, stare at you impassively whilst you try and piece together a coherent answer, then play all sorts of mind games with you once you actually come up with an answer. For example, they may ask - with a smirk or quizzically raised eyebrow - "is that really what you meant? Are you sure about that?" or worse, they sometimes ask another student "so, do you think he's right?"...and in the midst of such incredulity, I am often tempted to change my reply...only to be informed that I was right the first time all along. Words cannot describe how frustrating it is to get a question wrong because of self-doubt rather than lack of knowledge!

The medical side

My elective was a decent experience. I stayed in the UK, so if you're looking for stories about margaritas and Caribbean beaches or leprosariums (see "Extras") I'm afraid I have none to offer. I stayed in the UK mostly for financial reasons and because I thought I might have more learning opportunities. Yep, I'm a nerd. Since starting medical school, I have wanted to do pretty much every specialty there is, but for about a year now I've been quite attracted to emergency medicine. So I decided to do an elective in EM at a large UK trauma centre.

For the most part, what I did was quite similar to what I normally do on placement. I clerked in lots of patients, especially children in the paediatric emergency unit. I have yet to do my paediatrics block, so this was the first time (outside of GP block) where I've had the chance to clerk in children. It was a fun experience and one that I enjoyed. I realised that if I did want to do emergency medicine as a career, I'd probably want to subspecialise in paediatric emergency medicine. I also got the chance to brush up on the clinical skills I hadn't had a chance to practice in GP block e.g. taking blood and placing cannulas. I also got to do my first urinary catheter - not glamarous, but something I'll no doubt be doing as a foundation doctor, so a useful skill to get to grips with on a real person as opposed to a plastic model (it went in with no problems thankfully!).

I did a night shift and found it surprisingly un-crazy, though quite tiring too - by 5 AM I was really struggling to keep focused. I liked the team atmosphere in the emergency department, but I did feel quite nervous about simply slotting myself into a brand new department where no one knows me. I can't have been that awkward though since my supervising consultant gave me an "excellent" on my evaluation sheet for "integration into work environment", which was nice!

I observed the trauma cases and cardiac codes in resus and even got to have a go at chest compressions when a patient went into cardiac arrest in the cath lab following a heart attack. I marveled at the brutal efficacy of the Lucas2 machines - there's no denying it, emergency medicine is exciting! You just don't see traumas or cool equipment like this on a normal ward. These aspects of emergency medicine were certainly interesting, but not a regular occurrence, contrary to what TV wants us to believe.

However, I found the lack of continuity a bit frustrating - whenever a patient was sent home to see their GP for further investigation or admitted to a ward, I kept wondering what happened to them! This was actually a big sticking point for me and made me think that emergency medicine perhaps isn't for me...I want a specialty where I get the feeling I've completed the job, as it were. I'll write more about this at a later date as it deserves its own post. I did follow up the patients who were admitted to the ward though, and it was gratifying to see that many times when I had clerked them in, the medical or surgical team who received them also had the same differentials in mind as I had.

The non-medicalside

I think the most important thing I learnt wasn't actually related to medical science at all though. This was the first time I've ever worked with medical students from another university in a hospital environment. It made me realise something - medical students are all largely the same wherever we are in the country. We do the same tasks, get frustrated by the same things, have to complete the same sort of logbooks, sign off sheets and other bureaucractic things. We all feel overwhelmed, unconfident and can flounder under pressure whilst being grilled.

This sounds really obvious, but I think I'd sort of lost sight of it and for a long while I suppose I'd been erroneously assigning many of my frustrations to MY medical school, rather than the medical school process on general. I assumed everyone else was having a great time and I was the only one feeling cross about this and that.And that's meant that I've had a bit of a rubbish time as of late - every little thing that's gone wrong or been annoying has been due to MY medical school being a pain. But when I met and worked with other students from a totally different medical school, I saw that actually, they have the same grievances and worries as me. And that their med school makes them jump through the same hoops too, for better or worse.

By the end of the six week elective, I realised I actually really missed my medical school, the teaching hospitals, and even the region I work in. I came back to my university town and my flat, and I actually felt quite happy and content, something which I've not felt in a while. This newfound perspective was worth much more than any number of patient clerkings or trauma calls, as it means now I can focus on my remaining placements safe in the knowledge that whatever I'm frustrated by, it seems to be the same everywhere. So hopefully that's another of my New Year's Eve worries alleviated.

Next time

I'll talk a bit about specialties - I wanted to do EM for a long time, but I'll go into the reasons as to why I no longer think it's for me and why being a gasman might be.

Extras

For an account of a less typical medical elective, I would really recommend The Motorcycle Diaries.A great film and well worth a watch.

Saturday, 11 April 2015

I really need to update this thing more regularly - it's supposed to be for my own therapy so I have somewhere to discuss my feelings etc, but I neglect it shamelessly. Aside from anything else, it gives off the impression that I only come here to make negative posts. Talk about publication bias!

General Practice

GP was in January and February. From my last post I think it's quite apparent that I was in a very low period...2014 had been a very tough year and it hadn't ended amazingly well. A trip to GPland was just what I needed (though I didn't realise it at the time). So often as a student on hospital placements it's easy to feel totally disconnected as you try to slot yourself into a busy ward on a temporary basis. It's very easy to feel "in the way" and especially if you end up attached to a team where the consultant doesn't really take an interest in teaching you, it's very easy to feel lost, which raises stress levels, which doesn't help learning or mood.

Thankfully with GP it was different. My GP consultant was very friendly (as were the nurses, receptionists, patients and the caretaker!) and very keen to get me involved in seeing and managing the patients. The block was extremely well organised with regular teaching and clinical skills sessions, and all the tutors were really helpful and keen. It's the first block I've had since starting clinical medicine where I've felt I've really been able to enjoy myself with minimal stress.

It's also the first block where I've felt there's been enough time to actually talk to the patients. On a busy ward it's so easy to feel like a spare part, even if you take the time to take a history from a patient and present it back to a junior doctor it often feels like you're not really making a difference. But in the GP practice there was enough time to see the patient (who's often coming in with a brand new problem), come up with a diagnosis and a plan, present it back to the GP, then have it acted on. It felt like I was actually doing something. Me, the student!

I think the best way of alienating a medical practitioner (even one as formative and junior as I) from their job is to make them feel ineffective and as if their work boils down to box ticking and meeting targets. Targets can come in all different kinds of sizes and shapes, from government ones to med school demands on the number of reports you need to hand in per block. GP block does not have any reports which need to be submitted, just a logbook, so I was able to spend this eight weeks solely immersed in the medicine as opposed to running around trying to get signed off for this and that. Getting reacquainted with just how fun and amazing talking to patients can be is exactly what I needed to regain my motivation - something I was quite concerned about on New Year's Eve!

Exams

In mid-March I passed my first summative exams since starting the clinical phase of my course - very pleased with that! It had been a stressful few weeks leading up to the exams (as usual) and there had been no time set aside for study leave. I finished GP block on a Friday and the exams began on the Monday - but thankfully I managed to pass both written and practical parts which means...

...I roll onto the final year of medical school in September! It's nearly all over! Finals to go this time next year, then god help us all, I might actually be a doctor!

And I have more confidence in myself now since the fact that I've passed means that I must have been learning in an effective way since I started clinical medicine 14 months ago. Again, this was something I was worried about on New Year's Eve, so it's good to have some confirmation that things are going to plan!

Elective

Educational and illuminating - I'll do a proper post on this in a couple of weeks when I've finished.